Secrets From the Project Team

Build the ultimate ASC with these strategies from the front lines.

When the Cleveland Clinic announced that a new ambulatory surgery center was being constructed in Palm Beach, Fla. this year, the industry took notice. As the No. 1- ranked heart care center for more than three decades, the clinic has become a figurehead, especially as more surgeries move into the outpatient realm.

The goal, explains Tom Mihaljevic, MD, CEO and president of Cleveland Clinic, is flexibility to adapt toward the future of outpatient surgery. “Our expansion plan will transform care for the community with a new hospital and outpatient clinics that provide a broad range of specialties, greater access and innovative patient experience programs,” he says.”

Dr. Mihaljevic explains that having the flexibility to adapt and add specialty care is a must for a new ASC in today’s surgical landscape, which includes focuses on everything from heart, vascular and thoracic care to cancer treatment and pediatric surgery.

Who you know

How to get from idea to reality is a long road, but when it’s paved with experts, the process can be much smoother.

A good rule of thumb: hire people you trust with experience specific to ASC construction, including a project manager, architect and general contractor. These are the people who can be relied on to help bring additional team members on board, such as finance companies, attorneys, medical equipment providers and IT experts, as well as mechanical, electrical, plumbing and landscape companies.

Culling team members from diverse backgrounds and areas of expertise can influence the ASC design process for the better, ensuring a thorough understanding of the project requirements from the start, says Lisa Spruce, DNP, RN, CNS-CP, EBP-C, CNOR, ACNS, ACNP, FAAN, senior director of evidence-based perioperative practice at the Association of periOperative Registered Nurses (AORN) in Denver. “By aligning their efforts, team members strive to create an ideal patient-centered operating room environment” for the future, she says.

Considering that it can take 18 to 24 months to construct an average-sized ASC, at least according to the industry standard from design to final CMS approval, most experts agree that no matter how solid a plan is going into construction, it’s not unreasonable to add another 12 months to account for any potential setbacks, such as zoning approvals, construction delays and regulatory red tape.

“You need a well-defined project schedule with realistic timelines for each phase of the build.”
-Shakeel Ahmed, MD

Insurance approvals are another area that can cause delays up to six months since an ASC cannot secure those approvals with private payors until it has a Medicare number, which is only receives after performing procedures.

Other considerations to pencil in early: infection control, ADA compliance and overall safety standards from accrediting bodies like the Accreditation Association for Ambulatory Health Care (AAAHC) and The Joint Commission.

Eyes on the prize

In every successful building project, there are a few critical factors that need to be in place from Day 1, says Shakeel Ahmed, MD, MRCP, FACP, FAGC, FASGE. Dr. Ahmed, CEO of Atlas Surgical Group in St. Louis, has been involved in dozens of surgery center projects in the last few decades.

First, it’s all about choosing the best possible location for the center to ultimately be successful. In most cases that means being close to local hospitals and healthcare facilities that can provide referrals and a continuity of care.

“Budget is another critical factor,” says Dr. Ahmed. “Many great ideas have failed due to inadequate financial planning, especially when dealing with the complexities of ASC construction. Additionally, regulatory compliance is a big hurdle.” He notes that failure to understand and adhere to local and federal laws can halt a project before it gets started.

Thirdly, design is integral to being able to serve patients and to do so in the most accessible ways. “These elements will define your center’s long-term success,” he says.

A patient-centered design focus allows a new ASC to adapt to the changing needs of patients and technology. Key considerations are:

• Comfort and privacy. Ensure patients have privacy throughout the process, including in the waiting room, while checking in, during procedures and in recovery spaces. There are ways to use soundproof materials to transform even the smallest spaces into more private ones.

• Clear signage and a logical layout. This helps guide patients to where they need to go easily and without any additional anxiety. Minimizing wait times can also enhance the experience.

• Optimized flow. A layout should be designed to reduce unnecessary steps for the clinical team. Ensure easy access to supplies and equipment. Procedure rooms also work best when they are near recovery areas to lessen patient transport time.

Nuts and bolts

When it comes the actual construction of a new ASC, Dr. Ahmed says that deadlines are mission-critical to staying on timelines and not going over budget.

“You need a well-defined project schedule with realistic timelines for each phase of the build,” he says. “Over the past 25 years of ASC construction, I have found that poor timeline management is the No. 1 cause of frustration and financial discord in ASC projects.”

Surely anyone who’s been involved in a construction project knows that issues can and probably will arise, but that doesn’t mean you need to lose momentum.

“Always build a buffer for setbacks and extra expenses,” advises Dr. Ahmed. He also recommends establishing a contingency plan from Day 1 so that unexpected delays don’t derail an entire timeline.

Another good way to stick to deadlines and budgets is to hire experienced consultants and conduct regular inspections and audits throughout the entire construction process.

“I rely on a rock-solid team of specialists covering every facet of ASC development,” says Dr. Ahmed. These include nursing consultants, architectural experts and regulatory compliance advisors at both the state and federal levels. “They will ensure your facility meets every requirement and that no critical detail gets overlooked. Cutting corners can be costly, financially and legally.”

Even with a crack team in place and a solid building plan, it’s inevitable that setbacks will happen. Dr. Ahmed says it’s not unusual to face zoning and regulatory hurdles at the state and local levels. There can also be supply chain disruptions in the new economy, unforeseen site conditions, parking issues and even design flaws that fail to account for the actual patient volume a center is expected to handle.

Years ago, when Dr. Ahmed was developing a multi-specialty surgery center in the Midwest, a robust medical gas system was installed using a nationally recognized ASC provider. “Everything was installed perfectly until we hit an unexpected zoning issue, he says.”

Ultimately, the local government refused to approve the installation because the workers did not have a local license. “Their national certification meant nothing to these small-town bureaucrats. The entire system had to be uninstalled, discarded and reinstalled by a locally licensed company resulting in tens of thousands of dollars in lost revenue and weeks of delays, he says.”

The lesson? Never assume national standards will override local requirements. Always verify zoning laws and licensing mandates in advance.

A bright, high-tech future

Most ASCs are becoming increasingly high tech to accommodate a much more diverse range of outpatient surgeries. For example, hybrid OR rooms and robotics operating rooms are fast becoming the norm.

Here are three key tech areas to consider today:

• Telemedicine for virtual preoperative consultations and follow-up visits allow patients to discuss their procedures, ask questions and receive post-operative care remotely, which helps to reduce the need for in-person visits.

• Advanced imaging technologies with high-definition and 3D visualization tools allow surgeons to plan and execute procedures more precisely, resulting in reduced surgery time, less trauma and quicker recovery for patients.

• AI-driven tools help predict patient outcomes and personalize care to enhance decision making and patient risk stratification to improve overall surgical planning and patient safety.

“The evolution of outpatient surgery centers through these technological advancements is transforming patient care by making procedures safer, more efficient and more patient-friendly,” says AORN’s Dr. Spruce.

She predicts ASCs will become more flexible with what procedures they can accommodate overall. “One way they can do this is to design operating rooms with modular equipment and adaptable layouts that can quickly accommodate diverse types of surgeries,” explains Dr. Spruce. “They can also create versatile recovery areas that can be configured for diverse types of procedures and patient needs.”

Another way to become more flexible is with adaptive staffing models and cross-training staff, like surgical and support personnel that can be trained in multiple roles to allow for flexible staffing solutions based on current demand and procedure types.

“When I worked in an ASC as a circulating nurse, I cross-trained to pre-op, PACU, and the GI lab so I was available to flex my role at any time depending on the needs of the ASC and patient population on any given day,” says Dr. Spruce, who would like to also see every new ASC implement an Enhanced Recovery After Surgery (ERAS) program. The implementation of evidence-based protocols optimize patient recovery. These ERAS protocols focus on optimizing the patient’s health before surgery, having a pain management plan that minimizes the use of opioids and focuses more on nutrition and mobilization, allowing patients to recover more quickly and safely at home.

“I think ASCs should focus on having a patient-centric design with the goal of creating welcoming, comfortable environments with private recovery areas, reducing anxiety and enhancing overall patient satisfaction,” says Dr. Spruce. Comprehensive preoperative and postoperative care that offer integrated services like physical therapy, pain management and follow- up care can enhance recovery processes and reduce readmission rates, she adds.

COVID has reshaped the industry in many ways, and potential future emergent health issues have certainly impacted the way new centers are being designed. “We learned that the healthcare environment can change rapidly, which poses challenges to any healthcare system, including the ASC,” explains Dr. Spruce. Newly recognized pathogens and well-known organisms that have become more resistant to current treatment modalities are causes for concern. Protecting patients and personnel from transmission of potentially infectious agents should be a primary focus.

“All ASCs need a comprehensive plan in place to implement standard and transmission-based precautions to prevent pathogen transmission by using conventional capacity strategies, as well as a plan for emerging infectious disease preparedness, she says.” OSM